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THE COMMONWEALTH OF MASSACHUSETTS
—\ BOARD OF HEALTH`S
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Appliratiuit for Disposal Morks Tonstrurtiun 11nmit
Application is hereby made for a Permit to Construct (L./) or Repair ( ) an Individual Sewage Disposal
System at -
'r G 0-( 13.__ V.A L H A L A tit► v£ .. ........... .. ........... S<S�S �t5?-5- - p l v 4Lat
... .._._. 5." 3......�
Location- Address.".... ....-..-... -' - Z —JG .. or Lot No.........».» »
.. W-E�NI _ .».....
Owner dress
C.'.�-."---" - .. p - .. - i . t £3 �...1!:f J .............
Installer Address-
Type of Building Size Lot...�....
Sq. feet
.-� Dwelling —No. of Bedrooms ..".........3 ............................Expansion Attic ( ) Garbage Grinder ( )
aa Other — T e of Building No. of persons ............................ Showers
YP g ---------------•--....._...-..---.....---•- ( ) —Cafeteria ( )
04 Other fixtures......................................_._--------__......._..........----•........_............------•.. .....-•-•--
Design Flow ................ 55.".........•...._.__gal lons per person tir day. Total daily flow......... Zd"-"-.-...... gallons.
Septic Tank — Liquid capacity.�1Q��__gallons Length" -.-"-...Z.. Width;...Diameter................ De th..... `�..`. 9FF
Disposal Trench — No. -------- .1.......... Width ---- 1A........... Total Length ...... 0......... Total leaching area .... 7- sgtt. 6�rJ
3 Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area ................. sq. ft.
Z- Other Distribution box ( ) Dosing tank( ) 4-2-.1
q
aPercolation Test Results , Performed by... f]ld�!1AS--"j✓f � 1 4N i� ......... Date ....-:�?.."3. _, -l.�' _
Test Pit No. 1 ---- -"-".--_:minutes per inch Depth of Test Pit...13........__ Depth to ground water... N?.4.f�!(Vc
LL, Test Pit No. 2 ... ..2 ....... minutes per inch Depth of Test Pit ... 1.5.�t____.__. Depth to ground water .....
..
O Description of Soil ....... .....0_' ."_"TZ1 ....�v ..j ... ED SAK)D 5�-- 109..F�NB_ ��4N� wI)}l
•--------
S►.!-..s,�_._..1N�..... ?......
- _ . raw wIH
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�1._S...�S--------��'--)r.�.._C!�AN ►��0- �rl� sA�,7..... X50_-�56 = F�! 6 '�°j:�...!ti jy 5j�7.5...............
UNature of Repairs or Alterations — Answer when applicable... _ .�1 f+' ��r<'� ? / __ L!g S
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of IME 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is u d by the boV4 of health.
Signed. .......................... .....
Dat
Application Approved By ....... ..._... _.__R.. . 1 --------------------- _"�.% 1eD _.
Date
Application Disapproved for the following reasons : .................................."..... --............_._.____...._...__..._._____..._......Dat e.......... ....
p o
---------------� _. _... 4._.Issued..........__
...--------.....................................................................
�......---...._....-------" _ � ....(.. .......................
Permit No ......... �'f}
ate
y
THE COMMONWEALTH OF MA$S/1CHUSETTS
BOARD OF HEALTH -
.........
(Intifutt#r of. Toutpl nurr
THIS IS TO CERTIFY, That the Indwldu 1 Sewage Disposal System onstr $ted, >e or/Repaired ( )
by...............................................I V .f'asst�. ...
•-�`'�
at r' . .Q G1A
K*-. F �r
h` s bee nst 1 1 ar r 1t y,:{ { ' ,1l 0 he tate nitary Code as s ed 19 it
'�j t " "aPP o �'; 11 V or'•s truction5ermit No.__ ..... _ f -- '
At f OF THIS ERTIFI;CATE SHALL NO BE ONSTRUED AS GUAR NTEE;THAT T E
SYSTEM WILL F TI N � SFACTORY.
4 -DATE Inspector-�r.�1.�... ( .